Dr. Sanjaya U Jayasooriya

Importance of low Sodium diet for hemodialysis patients

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A proper diet plan with low sodium diet for hemodialysis patients is one of the fundamentals for their long-term survival. Unless you follow a good diet plan, it would be challenging to face some of the issues associated with the diet in Chronic Kidney Diseases. Minimizing dietary salt is one of the essential parts of the management of CKD patients. Today, our concern is on “what is the importance of low Sodium diet for hemodialysis patients.”

What is Sodium?

Sodium is one of the widespread and essential elements on Earth. It is commonly found as sodium chloride (dietary salt). It has a lot of functions to maintain day to day functions in the body. LIke

  1. Maintain the neural transmission.
  2. Regulating blood pressure.
  3. Maintain Acid-base balance. 

However, the excess amount of sodium may give rise to a lot of problems for humans. Such as;

  1. uncontrolled blood pressure.
  2. Leg and body swelling.
  3. Difficulty in breathing. 

Therefore it is recomend to use low sodium diets for hemodialysis patients.

Recommended daily limit of Sodium intake

Most of our meals contain salts. It is estimated that the average American eats around 3500mg of salts each day. But both American Heart Association and the Food and Drug Administration recommended taking around 2300mg of salts (1Teaspoon) per day. However, the American heart association further suggests that it is better to reduce daily intake to less than 1500mg or even less(500mg).

Problems associated with high sodium in CKD patients

Chronic Kidney Disease patients often fail to maintain most of the kidney functions. They fail to remove excess fluids from the body. Also, they fail to maintain Sodium-Potassium balance in the body. Additionally, most of them fail to regulate blood pressure. 

High blood pressure is one of the causes of kidney failure. It also worsens kidney damage. Unless CKD patients maintain blood pressure adequately, there will be fast deterioration of kidneys. 

Therefore it is essential to maintain blood pressure during illness. However, excessive sodium intake may damage this blood pressure control. Therefore it is necessary to reduce dietary sodium intake in all Chronic kidney disease patients, including dialysis patients. 

Patients with End-Stage Kidney Failure are facing difficulties in fluid excretion. As a result, they accumulate water in the body. These fluids are distributed all around the body—legs, lugs, abdomen, etc.

Even hemodialysis may fail to reduce these fluids from the body when you take a high sodium diet.  

Importance of Low Sodium diet in hemodialysis patients

When you get renal failure, we often advise reducing dietary sodium intake to control blood pressure. Because a low sodium diet will prevent the unnecessary increase of blood pressure, this will preserve the kidneys in the long run. 

However, when you progress to End-stage kidney failure, you need to reduce dietary sodium further. This will reduce the unnecessary accumulation of fluids in the body. 

Also, high sodium amount in the blood can drastically change your blood pressure during hemodialysis. Therefore it is essential to take a low sodium diet for hemodialysis patients. 

How to select a low sodium diet as a hemodialysis patient

Although we are not fully aware, there are ways to reduce sodium intake in our diet as a hemodialysis patient. 

  1. Often select fresh fruits, vegitables, etc.
  2. Prepare your food by yourself.
  3. Look at the amount of sodium levels in each food item. 
  4. Identify foods that contain hidden sodium and avoid them.
  5. Use alternative natural flavors for your food items.
  6. Reduce the portion size of your sodium-containing foods. 
  7. Ask no- salt / fewer salts in your foods in restaurants. 

Importance of taking support from your dietician

As a patient undergoing hemodialysis, you can use all the above methods to reduce dietary sodium. However, your dietitian can help you make a proper low sodium diet that adjusts to your needs.

He will initially counsel you on the importance of a low sodium diet as a hemodialysis patient. Also, he will assess your current nutritional state and food habits. Then he can determine your sodium levels. After all, you can discuss your diet plans according to your most preferable foods. 

As a patient with CKD patient, your long term target should be to live longer with less complications. low sodium diet for hemodialysis patients is unavoidable factor in this issue. Therefore you have to meet your dietician and take necessary diet plan and proceed it to progress longer. Additionally you often have to get review your diet plan each 3- 6 months by your dietician.

Reference:

  1. Sodium in Your Diet, US food and Drug Administration
  2. How much sodium should I eat per day?, American Heart Association
  3. Chazot C, Collonge C, Charra B. Diététique hyposodée chez le patient dialysé: mythe ou réalite? [Low sodium diet for dialysis patients: myth or reality?]. Nephrol Ther. 2007 Sep;3 Suppl 2:S137-40. French. doi: 10.1016/s1769-7255(07)80022-8. PMID: 17939970.

Dialysis Related Amyloidosis – Beta 2 Amyloidosis in CKD

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dialysis associated amyloidosis

Amyloidosis is a rare but well-known complication of most of the long term illness. It is the deposition of abnormally folded proteins in the body compartments. However, we see a type of amyloidosis in patients with Chronic Kidney Diseases (CKD) and chronic hemodialysis. This is termed as dialysis related amyloidosis (Beta 2 Amyloidosis). Additionally This type of amyloidosis has found in patient with severe renal impairment, but has not undergone any dialysis.

Mechanism of Dialysis Related Amyloidosis

Our kidney is the most vital organ for the excretory functions of the body. Usually, it removes all the excess chemicals from the body. Beta 2 macroglobulin is also filtered out from the kidney. However, When someone has chronic kidney disease, they have to undergo regular hemodialysis to maintain regular kidney functions. But the artificial dialysis membrane fails to filter out the type of macroglobulin called beta 2 macroglobulin (a type of small protein) from the body.

The failure to remove the beta-amyloid associated macroglobulin can cause the accumulation of them in the body compartments. Some of the sites are the joints and synovium, heart, tongue, and some other organs.

Complications of Dialysis Associated Amyloidosis

Depending on the site of the deposition of the Beta 2 globulin, it cause different clinical signs and symptoms. Most often these patients presenting with chronic joint pains. However in addition to joint pains dialysis related amyloidosis causes lot of different clinical features.

  1. Chronic joint pain
  2. Carpal tunnel syndrome
  3. Cardiomegaly
  4. Heart failure
  5. Macroglossia (large tongue)
  6. Bone fractures

Carple tunnel syndrome due to dialysis related amyloidosis
Carpal tunnel syndrome in a Chronic Dialysis patient.

How to Prevent Dialysis Related Amyloidosis

All the patients who undergo chronic dialysis are prone to get dialysis-associated amyloidosis. It is estimated to have 50% of patients getting dialysis related amyloidosis with in 10years of dialysis. Additionally most of the treatment methods for dialysis associated beta 2 amyloidosis fail to completely cure the complications like chronic joint pains, bone destructions and etc.

Therefore it is essential to take adequate precautions to prevent this conditions in all patients undergoing hemodialysis.

Young patients are more prone to get dialysis associated amyloidosis as they are getting more dialysis. Therefore it is better to transplant them early as possible. Longer the duration of dialysis , higher the risk of DAA.

Early kidney transplant is the best method to prevent dialysis related amyloidosis.

However some of the patient with End stage kidney failure may not fit enough to undergo kidney transplant. In such situations we have to take some other methods to prevent this condition.

Most importantly maintaining the residual kidney function is necessary. This will patient own kidneys to function with limitations. As a result, kidneys are able to remove some of the beta 2 macro globulins from the body.

The percentage of beta 2 amyloidosis increase when we use low flux dialyzers. Therefore it is advisable to use high flux dialyzers. When we use high flux dialyzers, a larger pore size allows the dialyzer to remove globulins from the blood.

In addition to the dialyzer, there is important role of dialysate solutions. Therefore always use high quality dialysis solutions in each dialysis.

Some centers also use beta 2 macroglobulin filters to remove beta 2 globulins from the blood. This also reduce the plasma level of beta 2 globulins. As a result there is less chance of accumulation of amyloids in the body tissues.

Related articles

  1. Bardin T, Zingraff J, Kuntz D, Dru¨ eke T. Dialysis related amyloidosis. Nephrol Dial Transplant 1986; 1: 151–154
  2. Zingraff J, Noe¨l LH, Bardin T, et al. Beta-2-microglobulin amyloidosis in chronic renal failure (letter). N Engl J Med 1990;323: 1070–1071
  3. Mohamed OMH, Taher MM, Elfakey WEM. Beta 2-microglobulin amyloidosis causing carpal tunnel syndrome, mimic steal syndrome. MOJ Anat & Physiol. 2018;5(2):127-129. DOI: 10.15406/mojap.2018.05.00176

What is the best between hemodialysis vs peritoneal dialysis

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hemodialysis vs peritoneal dialysis

When you have Chronic Kidney Disease (CKD), you may have to undergo dialysis treatment. Although it is not at the beginning, you may need it in the End Stage of CKD. So you need to know the importance of dialysis as patient with CKD.

As the dialysis treatments has two main types: hemodialysis and peritoneal dialysis, you need to select one of them. So, what is the best treatment between hemodialysis vs peritoneal dialysis?

Why do you need dialysis?

In the latter stage of Chronic Kidney disease (CKD), you need to have Renal Replacement Therapy (RRT). RRT includes either transplantation of a kidney or regular dialysis treatment. 

Dialysis is a process of clearing out the unnecessary components of the body. This process includes some toxic elements, excretory products, drugs, etc. 

There are two main types of dialysis;

  1. hemodialysis
  2. peritoneal dialysis

Although hemodialysis and peritoneal dialysis function differently, the ultimate goal is the same. That is the replacement of the kidney functions of the body. 

What is hemodialysis?

Hemodialysis is a process of purification of blood. This process uses an external machine called the dialysis machine. The blood is taken out of the body. Then the blood is going through a dialyzer.  

Process of hemodialysis

When you undergo hemodialysis, you need to have vascular access to train the blood out of the body. You can have an AV Fistula, AV Graft, or some other type of access for this. 

Disadvantages of hemodialysis

Usually, the hemodialysis is done in a hemodialysis center or home. You need to undergo around three hemodialysis for a week. Also, it takes about three to five hours to complete. Therefore you need to adhere to a tight schedule to continue your regular hemodialysis. Also, you cant have long travel distances from your dialysis center. 

Complications of hemodialysis

It has some complications too. The dialysis-related hypotension, dialysis disequilibrium syndrome, Hypoglycemia, etc. are some of them. 

Advantages of hemodialysis

However, the hemodialysis is more effective in clearing out particles than the peritoneal dialysis. Usually, hemodialysis is beneficial in the latter part of the disease. Also, the risk of infection is very low. You do not feel much discomfort to have an AV fistula. 

What is peritoneal dialysis?

In peritoneal dialysis, we use the abdominal cavity to have dialysis. The peritoneal dialysis solution is inserted into the peritoneal cavity. Then we have to wait for 30 – 40 minutes for the dialysis process. Usually, we have to do it 3 to 5 times a day. 

Benefits of peritoneal dialysis

Disadvantages of peritoneal dialysis

When you undergo peritoneal dialysis, you have to have proper training. Also, it would help if you had an aseptic area. It would also be best if you had adequate time to have peritoneal dialysis several times a day. 

Complications of peritoneal dialysis

Also, peritoneal dialysis associate with peritoneal infections. Peritonitis is quite a lethal condition. Therefore you need proper handling during the procedure. But according to some researches, both hemodialysis and peritoneal dialysis have the same morbidity rates. 

Advantages of peritoneal dialysis

However, peritoneal dialysis is cheap compared to haemodialysis. You do not need to travel to a dialysis center for your peritoneal dialysis. You can freely continue your day to day activities and travel. Additionally, the newel methods like Continuous Ambulatory Peritoneal Dialysis (CAPD) have created fewer complications. 

 

What is the better option between hemodialysis vs peritoneal dialysis?

When you ask to start dialysis treatments, your nephrologist will discuss the method of renal replacement. If you are not undergoing a kidney transplant, you will offer another type of RRT. This option is either hemodialysis or peritoneal dialysis. 

But some people can’t undergo hemodialysis effectively, while others can’t have peritoneal dialysis. It would help if you discussed this with your nephrologist. He will explain you cons and pros of hemodialysis vs Peritoneal dialysis. 

Factors contributing to the selection of dialysis method

Usually, if your eGFR falls less than 15, you need dialysis treatments. But you need to select a better dialysis method for you. When you decide the better one between hemodialysis vs peritoneal dialysis, use the following factors. 

  1. Your preference between hemodialysis and peritoneal dialysis
  2. Distance to nearest hemodialysis center
  3. Affordability of dialysis treatment methods
  4. Possibility of insurance coverage of your treatment method
  5. Plan for transplants
  6. Level of education

So, now you would understand the decision between hemodialysis vs peritoneal dialysis is affected by a lot of factors. You need to consider all of them before the selection of one of them. 

Referance:

  1. Hemodialysis : https://en.wikipedia.org/wiki/Hemodialysis

How to continue haemodialysis during COVID 19 pandemic

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continue haemodialysis during covid 19 pademic

It is well known that the patients with End Stage Renal Failure (ESRF) are in high risk group for COVID 19 infection. However still you have to continue hemodialysis during COVID 19 infection. Because it is the only hope of your life. However it is mandatory to ensure the safety of both haemodialysis patients and staff during COVID 19 pandemic. Therefore this is a proper guide to get protected when continue haemodialysis during covid 19 infection.

Why Kidney disease patient need regular dialysis?

When you have End Stage Kidney Disease you have to undergo regular hemodialysis. This is to give the continuous kidney functions outside the body. This regular haemodialysis will ensure the proper execratory and other regulatory functions of the kidney.

However the haemodialysis is not a one time process. You have to repeat the dialysis in a regular basis like 3 times a weeks, 2 times a week or else. This regular haemodialysis is done at a hemodialysis center or at the patients own home.

Even in a situation like covid 19 , it is necessary part to continue haemodialysis without interruption.

How to be safe as a hemodialysis patient during COVID 19

Make sure you have safe dialysis center

When you are selecting or continue the hemodialysis during covid pandemic it is essential to find a place with proper infection prevention procedures. Specially it it has separate rooms for the each patient it will be beneficial.

Do not use public transport

Some people prefer the public transport than the private transport systems. This is not a good option for a CKD patient to have there transport during COVID 19. As they are less immune, they can get infected easily. Additionally they have a high mortality rate too.

Therefore find a near place for your haemodialysis. Use a private vehicle to reach the dialysis center.

Use facemasks

Face-mask is an essential item for covid prevention. When you are travelling in a public, you always need to wear a mask and follow necessary infection prevention protocols.

However if you use separate dialysis room, you do not need to wear a mask. But if its a common room, you have to wear a mask.

Practice proper hand washing techniques

Hand washing is alos a mandotory part of covid prevention. When you go away from your home, it is essential to practice hand washing. In addition use hand washing techniques before and after dialysis session.

Inform health staff on warning signs

When you use common dialysis facilities, you are also bound to protect the health of other dialysis patients too. Therefore it is necessary to inform the dialysis center about your warning sings of COVID 19 infection like fever, cough, cold etc.

Avoid the crowded places

When you are continue haemodialysis during covid 19 infection, it is necessary to minimize the exposure to the public. This include all social gatherings, visiting to the public places and etc.

This will avoid unnecessary troubles during covid 19 pandemic and ensure the safe hemodialysis.

How to safeguard the hemodialysis patients as health staff ?

In the corona pandemic we have to be safe whenever we are touching or dealing with patients. You may be doctor, dialysis nurse or dialysis technician attached to a dialysis center, whatever the occupation, you all have to be safe whenever possible.

methods of protection when doing hemodialysis during corona pandemic

As an staff member of the dialysis center, you have the responsibility to avoid the spread of covid through your dialysis center. Following guide will help you to continue hemodialysis during covid 19 pandemic.

Always screen the patients before entering to the dialysis center

Whenever a new patient or regular patient come for dialysis all of them has to undergo proper screening questioner to select the risk group of patients. The screening questioner should be covering recent visits, warning symptoms and etc.

Use separate rooms for risk groups

In some dialysis centers, they have the separate dialysis rooms. All the risk group of patients awaiting for dialysis has to inserted to these rooms. This will avoid cross contamination of corona infection.

Always use proper safety precautions during dialysis

Always you have to wear a mask, practice hand washing techniques and etc.

Use PPE when necessary during haemodialysis

When you continue the haemodialysis of the risk group of patients for COVID 19, it is always advisable to use a Personal Protective equipment (PPE). PPE will save you from corona infection while continue haemodialysis during corona pandemic.


Reference

https://www.cdc.gov/coronavirus/2019-ncov/hcp/dialysis.html

Can you live with one kidney – 4 essential facts

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Can you live with one kidney

Almost all human being has born with two kidneys. However there may be instances when you found a baby with single kidney. In addition there may be instances where you would find people with single functioning kidney due to various causes including obstructive uropathy, live donor transplant and etc. So can you live with one kidney?

What is the function of the human kidney ?

Human kidney has various functions in the body. Both kidneys work together to do provide adequate kidney function in body. The functions of the kidney are vary. It has lot of metabolic function to maintain the balance of the chemical balance in the body. In addition it has hormonal functions.

These are the list of functions of the kidneys;

  1. Produce urine and remove unnecessary amount of fluid from the body
  2. Remove waste products like urea, creatinine and etc.
  3. Maintain acid base balance of the blood
  4. Maintain electrolyte balance of the blood
  5. Produce glucose from the body (Glyconeogenesis)
  6. Produce Erythropoitein to maintain hemoglobin levels

Why there are a two kidneys ?

If you want to know the answer for “can you live with one kidney”, you probably me think why we have two kidneys instead of one. So there may be different explanations for the reasons for two kidneys. However scientist define this as the “Bilateral symmetry” of the body.

Not only you have 2 kidneys, but also you have lungs, eyes, hands, foots, ears and some of other organs as pairs. So when you have some organ as a pair, it two clones of the organ can work cooperatively to achieve its function. Likewise two kidneys can function better than single kidney.

What are the conditions causing single working kidney?

Sometimes you might not believe that there are people who born with single kidney. (unilateral renal aplasia). Usually it is around 1 /1000 live births. In addition there are some other instances for having one kidney.

Unilateral renal aplasia

As mentioned above some babies born with only one kidney. It may be either right kidney or the left kidney. Unilateral renal agenesis usually do not show any symptoms, unless you detected it by chance. In addition you may notice the absence of one kidney due to renal failure which developed later. This is usually due to rare genetic mutation.

Single kidney

Horse-shoe kidney

Congenital horse shoe kidney is another type of problem arises at birth. Even though you have two kidneys, they are fused together and worked like a one kidney.

Unilateral kidney failure

In some situations you may have to face disease conditions like obstructive uropathies due to posterior urethral valve, urinary calculi, urinary track strictures and etc. In such situations, there is a risk of kidney failure in one side.

Donor of kidney transplants

There are some instances you would find people with single kidney due to the live donor kidney transplants. If you become a donor of a living-donor kidney transplant, you have be with only one kidney through out the life.

Can’t we live without two kidneys?

Even though we have two kidneys, most of the patients with one kidney lives fairly normal. Additionally sometimes we do not even notice these patient with unilateral renal aplasia as they do not show any symptoms to the outside.

Therefore it having two kidneys is not a necessary part of maintaining the renal functions. Rather it plays a function of reservoir for future benefits.


How can you live with one kidney through out the life?

One of the common problem for kidney donors is “whether can I live with only one kidney after the donation?” So simple answer is YES, you can live with one kidney. But you have to take precautions to protect remaining kidney.

Steps for live with one kidney

Undergo regular medical screening

When you have only one kidney, you have to protect the kidney through out the life. Unless you will loose the remaining kidney. Then you will have renal failure and has to be haemodialysis dependent patient. So it is necessary to under go regular medical check up and screening. Regular screening of blood pressure, blood sugar levels, Urine reports are some of the very important screenings to protect the kidney.

Control your blood pressure

High blood pressure is one of the common issue causing the renal failure. When you have only one kidney, it is necessary to have strict blood pressure control to protect the kidney.

Control blood sugar levels

You can live with single kidney only when you have good blood sugar control in addition to the blood pressure. Both these play a major role to damage the remaining kidney.

Seek medical advice early

Life with one kidney is not simple as you think. You need to take every possible effort to protect the remaining kidney. There are some special conditions you need to take medical advice soon as possible

  1. Pain during urination
  2. Fever with back pain
  3. Bleeding with urination
  4. Pus in the urine

Reference:

  1. https://en.wikipedia.org/wiki/Kidney

eGFR Staging of CKD – 5 important stages of kidney failure

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eGFR staging system of CKD

Chronic kidney disease has become a very common condition now a days. This is due to increased number of patients suffering from Non Communicable Diseases (NCD) like Diabetes and Hypertension. The diagnosis of a CKD is done by set of serum and urine analysis. eGFR – Estimated Glomerular Filtration Rate is one of the very important parameter for both screening and the diagnosis of CKD. All the patients diagnosed with CKD has to stage the condition with eGFR staging of CKD. This staging of CKD using eGFR is very important in monitoring of the illness and the treatment of it.

What is CKD?

Our kidney has lot of physiologically important functions like removal of waste products, production of urine and etc. However, there are some instances when your kidneys fail to achieve the expected level of functions. The long-term inability to achieve such is defined as CKD. Although there may be structural abnormality of kidneys in Chronic Kidney Disease, CKD is commonly the functional abnormality. However later you would have structural changes too.

What is GFR and eGFR?

GFR – Glomerular Filtration Rate is the key indicator of someones kidney functions. This indicate the average rate of solute filtration from the glomeruli. It is calculated by the filtration rate of Creatinine. Therefore GFR is depend on someones age, sex and race. eGFR is a mathematically calculated glomerular filtration rate. The calculated eGFR value is used for the eGFR staging of CKD.

The calculation of eGFR is done with the help of standard calculation formulae. It uses age, gender and race for this calculations. The result is given for the body surface area. The normal eGFR is more than 90ml/min/1.73m2 .


eGFR Staging of CKD (Chronic Kidney Disease)

The usual CKD staging has 5 main stages. It is stage 1 to stage 5. The stage 1 having minimum or no reduction of kidney functions while stage 5 has almost zero kidney function.

Normal eGFR

Usually eGFR for normal person is above 90 (>90ml/min/1.73m2). If you have normal eGFR, you have a good kidney function. However the normal GFR is vary according to age. Usually the normal level of GFR reduce with age.

20–29 116

  30–39 107

  40–49 99

 50–59 93

  60–69 85

  70+ 75

Stage 1 CKD

Stage 1 CKD is also can called “Early stage CKD”. Here there may be some features of Chronic Kidney Diasese, however the eGFR remains above the level of 90. These patients may have albumin urea while they maintain the normal eGFR levels.

Stage 2 CKD

When you have stage 2 CKD, there is a minimum reduction in kidney functions. The GFR is between 60 to 89. Although the impairment of kidney function is minimal, there may be features of microalbunurea.

Stage 3 CKD

Stage 3 CKD indicate a moderate to severe impairment of renal functions. When you have stage 3, the glomerular filtration rate remain between 30 to 60. There is a chance of oedema. At the stage 3 CKD you need a care of a Nephrologist. According to the eGFR staging of CKD, stage 3 is seperated to two sub stages. Those are stage 3A and stage 3B.

Stage 3A

Chronic Kidney Disease of Stage 3A have GFR between 45 to 60. In this stage of CKD, the reduction of kidney function remains in mild to moderate levels.

Stage 3B

Stage 3B CKD has a Glomerular Filtration Rate of 30 to 44. At the stage 3B CKD, you disease getting irreversible and there is a rapid deterioration of renal functions. Therefore you need a proper care by a Nephrology team at this stage.

Stage 4

CKD stage 4 is defined as severe limitation of renal functions. The range of glomerular filtation is 15 to 29. Usually there is a significant reduction of urine out put. There is a gross oedema and other features of CKD. Then a patient diagnosed with stage 4 CKD, they need to counselling on future dialysis or other renal replacement therapy options.In addition they may need to send for creation of vascular access, if they plan to proceed with haemodialysis.

Stage 5

According to the eGFR staging of CKD, stage 5 Chronic Kidney Disease has GFR of less than 15. These patients have severe impairment of renal functions. Some patients have almost nil urine output. According to the guidelines of management of CKD, stage 5 CKD patients need dialysis.


Chronic kidney disease staging according to eGFR

End Stage Kidney Disease – ESKD

What is the End stage kidney diases (ESKD) according to the eGFR staging of CKD? This is other common question among kidney disease patients. Usually the stage 5 CKD is define as end stage kidney failure. However in some situations stage 4 also consider as end stage renal disease.

eGFR EPI staging of CKD

GFR is not always a reliable indicator in normal method of calculation. Therefore there is a recently introduced method of eGFR staging of CKD called eGFR EPI. eGFR epi indicates complex formula of epidemiological collaboration. This is more reliable method of CKD staging.

How to Check the eGFR levels

The diagnosis is Chronic kidney disease is done with assessment of kidney functions in two separate occasions in 3 months gap. The main investigation to diagnosis of chronic renal impairment is Serum Creatinine (S Cr) with eGFR test. This blood test will give you the amount of Serum creatinine and mathematically calculated eGFR. In addition we can perform a urine test to identify the red blood cells (RBC) and urine albumin levels.

serum creatinine

Except for the grossly reduced eGFR values you cant diagnose CKD with high amount of serum creatinine levels.

Reference

  1. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate [published correction appears in Ann Intern Med. 2011 Sep 20;155(6):408]. Ann Intern Med. 2009;150(9):604-612. doi:10.7326/0003-4819-150-9-200905050-00006

All about the haemodialysis and How to undergo dialysis?

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Haemodialysis machine / Hemodialysis

Haemodialysis is an artificial process to provide someone’s kidney functions externally via a machine called dialysis machine. Therefore Haemodialysis is very important process to maintain kidney functions in patients with Chronic Kidney Diseases and some acutely ill patients.

Why do we do dialysis in patients?


Your kidney have very important set of functions to maintain balance between lots of body functions. This includes excretion of waste products, removal of excess water from the body, maintain electrolyte balance, maintain acid base balance and etc.
If someone fail to maintain these kidney functions, they will be facing lot of problems
Eg:

  • Accumulation of water in the lungs (Pleural effusion)
  • Accumulation of water in abdomen (Ascites)
  • Excess Potassium in the serum (Hyperkalemia)
  • Reduced pH in the blood (Acidosis)

As most of above issues are life threatening timely dialysis is very important.

How need hemodialysis?


As mentioned, there are two groups of patients who need dialysis.

  1. Patients with Chronic Kidney Diseases (CKD)
  2. Acutely ill patient with Acute kidney injury (AKI)


Dialysis of CKD patients

Hemodialysis is one of the very important option in management of CKD patients. It will help to maintain most of the kidney functions.
This will ensure;

  • Removal of excess fluid from the body
  • Remove excess Potassium from the plasma
  • Maintain acid base balance


Dialysis of AKI patients

There are patients who get Acute Kidney Injuries (AKI) following different incidents. Viper bites, Sepsis, Leptospirosis are some of them. In such situations some patients undergo urgent haemodialysis.

How to dialysis a patient?


When we say dialysis most of the time it represents hemodialysis than the peritoneal dialysis.
When we do haemodialysis, the basic of this process is to take blood out of the body, purify it and re transfuse into the body. But this is very complicated process than this.

Steps of hemodialysis

  1. Prepare the dialysis machine
  2. Heparinize the vascular set properly
  3. Connect the patient through Vascular access to the dialysis machine
  4. Adjust all parameters of dialysis including UF, BFR, Heparin dose and etc
  5. Let blood go through the semipermeable membrane of the dialyzer
  6. Re transfuse blood to the patient
  7. Reinfuse the blood after completion of procedure
  8. Disconnect the Vascular line
  9. Await for hemostasis



Important parts of Dialysis procedure

image source : Wikipaedia

What is dialyzer?

As I mentioned, dialysis is an artificial process. So to give you kidney functions artificially, there should be an artificial kidney. Dialyzer is the one doing the function of an artificial kidney in the dialysis machine.

The dialyzers are made of synthetic semi permeable membranes. These membranes are capable of providing selective permeability to some of the molecules while others do not get it.
So dialyzer is the most important part of the haemodialysis machine.



Vascular access

When you want to undergo haemodialysis, you need to have an access point. This may be a AV Fistula, AV Graft, Perm Cath or Temporary Catheter. So each have different abilities. You should select your vascular access depending on your future dialyzing plan, vascular structure and lots of other factors.

However if you are undergoing an urgent haemodialysis, you have to use a temporary femoral or neck vascular catheter.

The vascular access will ensure the adequate blood supply to the dialysis machine. Also it will return all the purified blood to body.


Water supply

In a dialysis we are doing an invasive procedure to ensure the renal functions of the patient. However if we do not use proper water for this process, patients ended up with lot of complications. Sepsis is one of them.

Therefore we use a water plant with reverse osmotic systems.
This includes both filtering capacity of unnecessary particles and germs.


Complications of Haemodialysis

Although haemodialysis is a very important and effective treatment method, it may have lot of complications.

  1. Dialysis Disequilibrium Syndrome
  2. Hypotention during dialysis
  3. Hypoglycaemia
  4. Headache
  5. Fever
  6. Infections
  7. Bleeding from vascular access

Reference

https://www.ajkd.org/article/S0272-6386(05)00436-1/fulltext

Hypoglycemia during dialysis – 4 rare symptoms you should never miss

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Hypoglycemia during dialysis


I often see incidents of hypoglycemia during dialysis sessions. This is a common complication of dialysis in most of the hemodialysis centers. Although hypoglycemia is one of the very common complication during haemodialysis, more often inexperienced clinicians may miss these incidents. This article is mainly focus on how to detect hypoglycemia early, how to manage hypoglycaemia and how to prevent it.


Why is the hypoglycemia very common complication during dialysis?


It is true that we often see the patient undergoing clinical and subclinical hypoglycemia during dialysis. But why the dialysis patients are more proven to get hypoglycemic attacks. Is it the dialysis which causing the hypoglycemia? Or some other cause.


Diabetes mellitus can make you hypoglycemic


We know that one of the most common cause for CKD is the diabetes. Patients with diabetes often has high blood sugar levels. This is due to the insulin insensitivity or lack of insulin. So can these patients undergo hypoglycemia during hemodialysis?

Some of these CKD patients on Metformin, some are on other oral hypoglycemic agents like Gliclacide. Even if the metformin do not cause significant hypoglycemia, some other medications can cause the hypoglycemia. In addition Insulin can cause on and off hypoglycaemic events.


Kidney disease can also cause hypoglycemia

Gluconeogenesis is the process of creating glucose inside the body. This mainly occurs when you are in a fasting state. The kidneys are the second most vital organ for this mechanism. It is second only to the liver. When you have CKD, structure of your kidney get damaged and ability of gluconeogenesis is also get reduced. As a result body fails to maintain the adequate amount of the blood sugar levels during dialysis or even at the day to day settings.

Mechanism of dialysis

Dialysis is a complicated process. There is a 15g to 20g of glucose loss during each dialysis session. This loss of plasma glucose can lead to subclnical hypoglycemia in most of the patients. However in some patients they are not fit enough to maintain this loss of glucose during dialysis. Therefore they can get a significant hypoglycemia during dialysis.

Therefore hypoglycemia during dialysis is a multifactorial complication. Although loss of glucose during dialysis do not cause significant symptoms, failure to maintain the gluconeogenesis causing the significant damage to the patient.


How to identify the hypoglycemia during dialysis?


In a usual setting an experienced healthcare professional can identify the hypoglycemic events easily. But during dialysis it is very difficult to identify the hypoglycemic events.
As an experienced clinician I have met patients with blood sugar levels of 20mg/dl but they were almost normal except few symptoms. But this is not a viable blood sugar level in a normal patient.
Therefore you need to have clear understanding about hypoglycemia during dialysis. If you are not specifically look it, you can’t identify most of the hypoglycemia during haemodialysis.


Symptoms of hypoglycemia during dialysis sessions

  1. Hypotensive attacks
    Hypotension is the main symptom of low blood sugar levels during dialysis. If a patient develop a hypotension during dialysis, 1st thing to look is the hypoglycemia. Most of the times it is low blood sugar levels than the depletion of volume or some other cause.

  2. Failure to maintain blood pressure with inotropes
    This is a common issue with patients undergoing the urgent hemodialysis due to Acute Kidney injuries. Most of they are critically ill and on inotrope support. But if a patient do not improve with proper inotrope support, we have to look for the hypoglycemia.

  3. Altered level of consciousness
    Level of consciousness is a broad term. It include the orientation, the way of talking, level of intelligence and lot of other factors. In some instances I have met CKD patient with less than 20mg/dl blood sugar level with no significant alteration of consciousness.
Incidents of low blood sugar during dialysis

Case 1. 27years old patient came to regular hemodialysis. He maintained his blood pressure levels and saturation well. No complaints too. But when I talk to him, I found some irrelevance of his sentence to each. I had some suspicion and checked the blood sugar level. It was 17mg/dl and immediate actions were taken.

Case 2. 54years old patient was in his regular haemodialysis. He was given a cup of tea while he was on dialysis. But the staff member noted that he failed to take his tea. He informed me. Then I asked for a blood sugar level. It was 27mg/dl and he was collapsed in few second. Immediate resuscitation was conducted and successfully recovered the patient.

  1. Sweating during dialysis
    Sweating is a very common symptom of hypoglycemia. You can see it even in patients taking medication for diabetes. However surprisingly I rarely met hypoglycemic patients with sweating during dialysis. So I think you have a clear understanding on symptoms of hypoglycaemia during dialysis sessions. Then the next question is how to manage the hypoglycaemia during dialysis.


How to manage hypoglycemia during dialysis?


As I mentioned events of hypoglycemia is common and subclinical most of the times. However there are times you have to attend on events of hypoglycemia. Even if the pre dialysis and intradialysis blood sugar monitoring can be done, it is not a good and presence experience to patients. Even though the basic management of hypoglycemia is same in each complication, you have to attend the case depend on the symptoms too.

Hypoglycemia with hypotention.

Here the management of both hypoglycaemia and the hypotension should be done simultaneously.Soon as you note there is a hypotension the next action is to check the hypoglycemia.

  • Start bolus of 100cc normal saline
  • Give 1 vial of dextrose
  • Reduce the blood flow rate and position the patient
  • Repeat the blood pressure and blood sugar in 10 minutes
  • If blood sugar is not enough repeat the dextrose infusion

Hypoglycemia with no response to inotropes

Inotropes are the medications to improve the blood pressure in critical patients. They have different actions. It is common that patient face significant reduction of blood pressure soon as they are connected to the dialysis machines. But it can be picked up with these medications. But if these patients do not improve the blood pressure with inotrope, it is worth to check the blood sugar level than next inotrope.

Hypoglycemia with altered level of consciousness

Hypoglycemia is not the only cause for altered level of consciousness during dialysis. There are lot of cause like electrolyte imbalance, stoke and etc. In addition there is a very important condition called Dialysis disequilibrium syndrome.

But before thinking of anything else, you should focus on hypoglycemia during dialysis. Because it is easily preventable cause for altered level of consciousness during dialysis.

Whenever a patient has a reduce level of consciousness;

  • Check the blood pressure
  • Check the blood sugar levels
  • Look at the other neurological features
  • Give bolus of dextrose irrespective of blood sugar levels unless it is too high
  • Then only you can exclude other causes of altered level of consciousness.



Hypoglycemia with sweating during dialysis


Sweating is another presentation of hypoglycemia. But when someone has the sweating, it myocardial infarction should be ruled out.

  • Check all vital parameters
  • Give dextrose
  • Check urgent ECG


How to prevent hypoglycemia during dialysis


Although hypoglycemia is commonly missed as subclinical incidents, we have to be prepared and look into it properly.

  1. Ask patient to have proper meal prior to dialysis
  2. Arrange a mid-dialysis snack or refreshment
  3. Monitor CBS in high risk patients



Reference:

  1. Vadakedath, S., & Kandi, V. (2017). Dialysis: A Review of the Mechanisms Underlying Complications in the Management of Chronic Renal Failure. Cureus, 9(8), e1603. https://doi.org/10.7759/cureus.1603
  2. Abe, M., & Kalantar-Zadeh, K. (2015). Haemodialysis-induced hypoglycaemia and glycaemic disarrays. Nature reviews. Nephrology, 11(5), 302–313. https://doi.org/10.1038/nrneph.2015.38

Dialysis Disequilibrium Syndrome (DDS) – Rare but serious complication of dialysis

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Dialysis disequilibrium syndrome (DDS)


Have you ever experienced a sudden headache or confusion during your dialysis as a patient? Have you ever experienced a sudden neurological deterioration in your patient during or soon after the dialysis as a physician? The dialysis disequilibrium syndrome can be the reason for the unexplained neurological issues like headache, confusion, seizures, nausea and some of the other symptoms in dialysis patients. So what is this Dialysis Disequilibrium Syndrome (DDS)?


Basic mechanism of dialysis

Before understating the dialysis disequilibrium syndrome, it is good to know the basics of dialysis and how it works on your body.

If your kidney get Acute Kidney Injury (AKI) or Chronic Kidney Disease (CKD), you may have to undergo a process called dialysis. What we do as dialysis is the providing of natural kidney functions by an artificial kidney attached to machine. The most important function of dialysis is the removal of waste products from the body like urea. In addition it help to maintain acid base balance and electrolyte balance of the body.

You can see more about dialysis here.

If you have understood this basic of dialysis, you might understand that urea is removed in each session of the dialysis.


Mechanism of dialysis disequilibrium syndrome (DDS)?

Osmotic pressure of our body is basically maintain by two particles. One is the Sodium (Na+). Other one is the Urea. Even though other electrolytes are affecting this process, only these two can give significant contribution to oncotic pressure.

As we mentioned we remove some amount of the urea with each dialysis. Therefore there is a reduction of osmotic pressure in the blood. When plasma osmotic pressure reduced, it can cause cells to take some fluid from plasma and keep the balance between them.

Mechanism of dialysis disequilibrium syndrome (DDS)

Same process occurs in the brain too. This will ultimately result in increased size (edema) in the brain cells. This cerebral edema can cause lot of neurological issues simply from headache to death at last. When the amount of removed urea is higher, the edema is higher and risk of dialysis disequilibrium syndrome is higher.


Who get the disequilibrium syndrome?

Dialysis induced disequilibrium syndrome (DDS) is commonly seen in patient who undergoes their 1st series of dialysis. However it can also be seen in other CKD patients too. Some studies show that it is common in patients who miss their dialysis sessions.In addition it can present in some patients who undergoes dialysis or CRRT following acute kidney injury.


Symptoms and signs of disequilibrium syndrome

Cerebral edema following disequilibrium syndrome
  1. Headache
  2. Nausea
  3. Dizziness
  4. Confusion
  5. Visual disturbance
  6. Tremor
  7. Seizures
  8. Coma


How to prevent disequilibrium syndrome

Few decades ago, DDS is one of the common issues during dialysis. However with the development of the Nephrology and dialysis care, the disequilibrium syndrome has become a rare condition among the patients with Chronic Kidney Disease. Even though the dialysis disequilibrium syndrome is a rare complication, this should be considered as on of the serious complication of dialysis.

  1. Initiate the dialysis with short cycles
    Usual hemodialysis session are continue upto 4 to 5 hours. However at the initiation of the dialysis, it is advice to limit the duration of dialysis for few hours. Usually 2.5hours – 3hours as maximum. As a result the risk of sudden reduction of urea is rare.
  2. Use low blood flow rate
    When you dialysis, you can adjust the blood flow rate though the machine. Higher the rate of blood purification, higher the risk dialysis disequilibrium syndrome. Therefore you can try with a blood flow rate of 100 – 150 in initial dialysis sessions.
  3. Monitor the Urea Reduction Ratio
    Usually you can monitor the urea reduction rate with pre and post dialysis blood urea samples. So if the URR is high, you can reduce the other parameters in future dialysis.
  4. Initiate with low Ultrafiltrate (UF)
    In each dialysis session, we remove some amount of water from the body. When the volume of blood reduced, it cause sudden imbalance on osmolality. This also can lead to DDS. Therefore use low UF in early dialysis sessions.


Summery

As a summery dialysis disequilibrium syndrome (DDS) is not a common complication in novel Nephrology and dialysis care. However it was a common complication in history of hemodialysis. Why is this so important? Importance of dialysis disequilibrium syndrome is that its severe neurological complication. These can cause even sudden death. Therefore we have to take necessary precautions to prevent this condition during dialysis.


Reference articles

  1. Zepeda-Orozco, D., & Quigley, R. (2012). Dialysis disequilibrium syndrome. Pediatric nephrology (Berlin, Germany), 27(12), 2205–2211.
    https://doi.org/10.1007/s00467-012-2199-4
  2. S.M.Silver MD, R.H.Sterns MD, M.L.Halperin MD, Brain swelling after dialysis: Old urea or New Osmoles? American Journal of Kidney Diseases, Volume 28, Issue 1, July 1996, Pages 1-13
    https://doi.org/10.1016/S0272-6386(96)90124-9

AV Graft – Better alternative for AV fistula

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AV graft


When someone need to have regular haemodialysis, our first question is what can use as his vascular access for dialysis. Usually our first choice is AV fistula. However often have to try for AV graft (Arterio Venous Graft) too. Usually in US population, 15% patients undergoing hemodialysis use the AV graft instead of any other method. Although it is not the most superior method as permanent vascular access, we have to select this as the first choice in some set of patients.


What is AV Graft?

AV graft or Arterio Venous Graft means an artificial connection between arterial line and the venous line. We use an artificial hollow material to create the surgical connection between two vessels. Usually this connection is created in elbow pit.


When to use the AV graft?

As we mentioned earlier, Av graft is not the most effective method of permanent vascular access for haemodialysis. However in some special situations, it is the first choice as a vascular access for dialysis.

  1. Patient with inadequate venous access.
  2. Patient who need an access soon.


AV graft surgery

Advantages of AV graft

Can use for patient need urgent regular haemodialysis
When you use an AV fistula for dialysis, you may have to wait for another 3 -6 month to maturity of the fistula site.However Arterio venous graft do not take that much of time to initiation of the dialysis. Usually we can start the haemodialysis after 1 month of the surgery. This is due to the fast maturity of the graft site.

Can use in patients with small blood vessels
Formation of AV fistula is very difficult surgery. Especially it is difficult procedure in wrist area. This is because of the absence of the large blood vessels in this area. However Arterio Venous graft can be used even in patients with vascular issues.

Need only the local anesthesia
This surgery is done under local anesthesia. In addition it is performed as a day surgery. Therefore you do not need long hospital stay.


Disadvantages of Arterio Venous Graft (AV Graft)

  1. Insertion of artificial material to body
    We use synthetic material to connect two blood vessels together. Therefore we have to insert this synthetic material to the fistula site.
  2. Risk of closure
    Although the AV fistula is often last a long time, there is a high chance of AV graft to get blocked by frequent blood clots.
  3. Risk of infections
    As we have placed a synthetic material in our body, it is often tend to get infected. Therefore careful handling is necessary.


How to prepare for AV graft

When you are diagnosed as having Chronic Kidney Disease (CKD), your nephrologist would discuss about the future treatment options with you. You need hemodialysis only if you become a patient with End Stage Kidney Disease (ESKD). However there may be some other instance you need a dialysis in an acute set up.


When your condition is getting worse you have to select a kind of option from Kidney transplant, regular haemodialysis, CAPD or no treatments. If you select to dialyze for long time, you need to select your vascular access for dialysis. As we already have discussed Arterio Venous Fistula (AV Fistula) is the most commonly used vascular access. However there are options like Arterio Venous Graft (AV Graft) and Permanent catheter. Your vascular surgeon will decide your mode of vascular access depending on your conditions.

What is better option between hemodialysis and peritoneal dialysis?

This is probably will do after a proper vascular mapping and physical assessment.
Then you will give a date for the surgery probably as outpatient setting.
After 2 – 4 weeks of surgery your vascular surgeon will allow you to puncture the fistula site.


How to handle the AV graft during haemodialysis

Whenever an AV graft or AV fistula is created it should be handle in a proper way. Unless the lifespan of the vascular access get reduced. Then we have to reconstruct the vascular access or we have to recreate a vascular access.

Complications of AV graft

You can apply some local anesthetic medication like lignocaine to reduce the pain during puncturing of the AV graft. But usage of subcutaneous lignocaine can increase the site of punctures.

You should handle the AV fistula in a way that minimum infections would be entered. Proper hand washing and disinfectants may be helpful to reduce the number of infections. Povidone Iodine solution can be used to clear the skin around the puncture site of the fistula.

You can use the same way as the puncture of the AV fistula for dialysis. That is puncturing of two sites of vein, one close to the arterial connection and other one way from the arterial connection.
You will use 16G AV Fistula needle for the procedure.

At the end of the dialysis session, you have to stop the bleeding with moderate pressure around the puncture site.

Proper use of heparin during dialysis will reduce the unnecessary bleeding will preventing the unnecessary clots.

Related articles

  1. Michael Allon MD, Charmaine E. Lok MD, MSc, FRCPC, in Handbook of Dialysis Therapy (Fifth Edition), 2017.
    https://www.sciencedirect.com/science/article/pii/B9780323391542000059
  2. Michael Allon, M.D., University of Alabama at Birmingham, Vascular Access for Hemodialysis, UCSF Department of surgery, 2014.
    https://surgery.ucsf.edu/conditions–procedures/vascular-access-for-hemodialysis.aspx